Basic Information
| Provider Information | |||||||||
| NPI: | 1396163226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REWIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2236 NW 145TH DR | ||||||||
| Address2: | |||||||||
| City: | NEWBERRY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326692029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043995550 | ||||||||
| FaxNumber: | 9043464334 | ||||||||
| Practice Location | |||||||||
| Address1: | 3599 UNIVERSITY S BLVD 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043995550 | ||||||||
| FaxNumber: | 9043464334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 02/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9107927 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA9107927 | 01 | FL | FLORIDA LICENSE | OTHER |